A little over two years ago I took a left hand turn in my career path when I joined a regional EHR program as their Project Manager. Having written and spoken about interoperability and digital health solutions, I wanted to “put my money where my mouth is” so to speak and devote my time and talent to realizing the vision that I so often advocated.

I am fortunate to be working with a dedicated group of people committed to making a difference for patients in Ontario. Whenever we are faced with a di cult situation or are choosing from what appear to be similar options, at least one member of the team always asks, “What is best for the patient?”

My wife is one of these patients.

Diagnosed about ten years ago with a chronic illness, Tracy recently embarked on a new journey to speak for those whose voices are not quite loud enough and to provide perspective to those who want to listen.

A talented writer, Tracy uses her blog to share her own experiences engaging the health system, offers insights on the view from the other end of the stethoscope (or, of interest to readers of this magazine, healthcare apps) and, from time to time, advocates for change.

Tracy has discovered, to her dismay, what others such as the McMaster Health Forum have observed: the patient is often not at the centre of care.

In a brief prepared to stimulate discussions by a citizen panel on strengthening care for people with chronic diseases in Ontario, the McMaster Health Forum notes:

“Health professionals don’t always work together to get people the care they need, despite this being important for improving patients’ outcomes.”

A briefing note prepared by the Institute for Clinical Evaluative Sciences (ICES) on variations in quality indicators across Ontario physician networks offers a similar perspective:

“Patients living with chronic disease have the best outcomes when they are treated throughout the progression of their disease,in a coordinated manner that engages all medical professionals involved in their care. However, in Ontario there has been a history of fragmentation of chronic disease care, leading to serious gaps.”

According to the McMaster Health Forum brief, access to their own health information can “help patients set goals for their health, manage their own care and better engage in decisions about their care with their providers.”

Unfortunately, the same brief also notes that there is “a lack of electronic health records that put all of a patient’s health information in one place” and, as a result, “patients also do not typically have access to their health information.”

As Internet pioneers and founding executives of several Internet start-ups (different companies before we met), Tracy and I both witnessed the creativity and innovation that was unleashed when entrepreneurs were given access to a platform (in this case, the Internet) on which to construct new applications and services

The banks recognize this same potential and are creating similar environments

to encourage innovation in financial services. Scotia Bank, for example, created the Digital Factory which they describe as a “hub for creation and incubationof new and partner-led ideas to deliver game-changing solutions for Scotiabank customers.”

Can the health system take a similar approach to encourage the development of applications and services to manage their own care and more e ectively engage their healthcare providers? Mohawk College and eHealth Ontario think so. They have partnered to create the eHealth Ontario Innovation Lab, an online, open provincial EHR platform that allows testing of digital health solutions in a virtual EHR environment.

Operationally and physically isolated from eHealth Ontario’s production environments, the Innovation Lab’s Virtual Lab Environment contains copies of eHealth Ontario EHR test environment assets and a fabricated, integrated EHR data set. These assets currently include the Ontario provincial client registry and the Ontario Lab Information System (OLIS), with the Ontario provider registry soon to be available.

Whether the eHealth Ontario Innovation Lab generates new and useful digital health solutions remains to be seen. At the very least, it provides developers with access to the provincial systems in which patient information is stored, information that patients can use to manage their own care and more effectively engage healthcare providers.

I recently shared Tracy’s blog with a friend of mine. He commented, with a wry smile, that we must have very interesting dinnertime conversations. We do. She inspires me each and every day to do what is best for the patient.

My Dad is the classic late adopter.He waits until a technology is mainstream and nearly everyone around him is using it before he adopts. Giventhat he now owns and uses a computer, an iPad and, most recently, an iPhone, I have started to wonder what computing technology will emerge that is equally transformative.

A recent Business Insider article claims that the computer industry moves in waves, with a “convergence of favorable economics and technical advances” driving a new wave every 10 to 15 years. I witnessed three of these waves, starting with what the Business Insider article refers to as the “PC revolution” in the 1980’s. This revolution spawned companies such as Apple and Microsoft and challenged established computer companies such as IBM.

The second wave of technological change began in 1990’s when the Internet moved from the universities and research institutes into the mainstream. Fueled by an established base of personal computers and the advent of the world wide web, Internet use exploded during the late 1990’s. This ubiquitous and inexpensive communications platform disrupted many industries, particularly those that relied on physical media that could be easily digitized or physical points of presence for the distribution of goods and services.

Over the past decade advances in miniaturization and wireless communication technologies transformed computing and Internet access from activities that could only take place in select locations to ones that take place anywhere, anytime. This third wave of computing, one often referred to as the “mobile revolution”, has quickly become an integral part of our lives.

The next wave of computing will take advantage of the infrastructure established during the first three waves along with the large, established base of users who, like my Dad, own at least one computing device and who access the Internet through these devices on a daily basis.

According to Vinod Khosla, Sun Microsystems co-founder, “there have been and will continue to be multiple big technology revolutions, but the most impactful on human society may be the one that finally builds systems with judgment and decision-making capability more sophisticated and nuanced than trained human judgment.”

While Mr. Khosla conceded in a November 2014 Forbes editorial that “any one software program may not do everything a human brain can do, he asserts:

“Specialized programs will likely makedecisions and predictions in their domain better than most trained humans. Many, if not most, domains will be well covered bysuch programs.”

Dr. Bertalan Mesko, the Medical Futurist, offers a similar perspective in a recent blog post, noting that while “we have not yet reached the state of ‘real’ AI (artificial intelligence)” … it is ready to sneak into our lives without any great announcement or fanfare.”

As an example of what is possible, Dr. Mesko cites a British application that helps people appeal parking tickets. This application successfully appealed 64% of quarter million parking tickets in both London and New York.

No one term seems to have emerged for this next technological wave. Some analystshave referred to it as “machine learning”while others use terms such as “artificial intelligence”. The Business Insider article to which I referred earlier notes that “none of these terms capture how widespread and roundbreaking this revolution will be” and suggests the term “robot revolution” is more appropriate. According to this article, the robot revolution will be “characterized by dozens of devices working on your behalf, invisibly, all the time, to make yourmife more convenient.”

In a blog post on the Medical Futurist website entitled “Artificial Intelligence Will Redesign Healthcare”, Dr. Bertalan Mesko notes this next wave of computing “could organize patient routes or treatment plans better, and also provide physicians with literally all the information they need to make a good decision.” Several examples cited in the blog post include:

Google Deepmind Health project that is using artificial intelligence to mine the data in patient medical records to provide better and faster health services. In its initial phase, Google is working with the Moorfields Eye Hospital NHS Foundation Trust to improve eye treatment.

IBM is applying its Watson artificial intelligence technology to identify the most appropriate cancer treatment plans for a patient. Watson for Oncology analyzes the meaning and context of structured and unstructured data in clinical notes and reports, and combines the insight gleaned from this analysis with attributes from the patient’s file as well as clinical expertise and external research.

Babylon, a British online medical consultation and health service, launched an application which offers a medical artificial intelligence consultation based on personal medical history and common medical knowledge. The recently launched application checks user reported symptoms against a database of diseases using speech recognition. After taking into account the patient’s history and circumstances, Babylon offers an appropriate course of action.

Not everyone enthusiastically embraces the promise of this next wave of computing. Vinod Khosla suggests that machine learning technologies might surpass humans in both intelligence and knowledge relevant to perform a particular job, thereby rendering human employees unnecessary. Mr. Khosla worries that “the machine learning technology revolution will lead to increasing income disparity, and disparity beyond a certain point will lead to social unrest.”

Others such as noted physicist Stephen Hawking and Tesla Motors founder Elon Musk fear that the artificial intelligence technology will become so sophisticated that it will try to take over our lives. An unabashed technology booster, I must confess that the implications of this next technology wave has given me pause to reconsider my position. Perhaps,as the Medical FuturistS suggests, we need to create ethical standards and consider gradual development of this next technological wave.

Do you agree that the “robot revolution” is the next wave in computing? If so, do you have any concerns about its impact? Please share your thoughts with me at michael.martineau@avenant.ca or on my blog at ehealthmusings.ca

The following article was recently published in Healthcare Information Management & Communications Canada, the journal for COACH members:

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As many industries have discovered, often painfully, digital technologies can be disruptive. Just ask Blockbuster, Kodak, or Postmedia. Is healthcare next?

In a presentation at the 2015 Marketing Transformation Forum, Ronald Velten, Marketing Director, Global Technology Services Europe at IBM Europe, identified three waves of digital disruption. In the first wave, starting in 1995, the shift from analog to digital content had a profound impact on music, photography, and video rental. The second wave, which started around 2010, has pushed many traditional media companies (print, radio, and television) to the brink of extinction.

More recently, in a third wave of digital disruption, new entrants, unencumbered by existing business models and legacy systems, are taking advantage of the constantly evolving digital landscape to enter markets previously considered immune from digital disruption. These new entrants are using digital technologies, not as tools to incrementally improve existing processes, but as weapons to disrupt the status quo.

Two examples of industries with perceived barriers to entry that once impeded digital disruption are taxis and financial services. Like healthcare, these sectors are subject to regulatory compliance and are dominated by well-established players.

That both these sectors are threatened by digital disruption is a warning sign that the health sector should heed. How each of these industries is dealing with the threat offers lessons that the health sector should consider.

Taxis

As recently as five years ago a taxi license was considered a good investment. Today, the price of these same licenses is in freefall in many cities. New competitors such as Uber are siphoning customers who once had few alternatives if they needed on-demand transportation services.

Taxis have, for decades, operated in a little-changed regulated environment. A GrowthHackers examination of Uber’s phenomenal and rapid growth notes:

“All told, very few people viewed finding and using taxi service as something enjoyable—it was simply something that they dealt with due to the lack of an alternative. Before Uber you were beholden to an entrenched, monopolistic entity, whose sloppy execution and lack of regard for the customer experience was evident at every touch point.”

A less colourful but equally stark comparison between the taxi incumbents and new entrants such as Uber can be found in a recent survey by Ipsos Reid (conducted for the City of Toronto as part of the city’s review of the taxi industry). The survey revealed that less than one-third (29%) of respondents were satisfied with taxi service while nearly two-thirds (65%) reported that they were satisfied with new market entrant, Uber.

How has the taxi industry and the cities that regulate them reacted to Uber’s entry into the market? The cities are tinkering with the regulations while the drivers protest.

According to a report by the Mowat Centre as part of the City of Ottawa’s review of taxi and limousine regulations, “Canadian jurisdictions initially adopted a reactive approach to ride-sharing firms, with cities such as Toronto, Ottawa, Montreal and Vancouver cracking down on drivers for by-law infractions or otherwise imposing barriers to operation.”

Even when overwhelming consumer demand forced many cities to reconsider their position and introduce regulatory reform, the taxi industry has continued to fight changes to the status quo.

Financial Services

Even the banks are getting nervous about the disruptive power of digital technologies. According to McKinsey & Company, banks could lose up to 60 per cent of their retail profits to financial technology startups (often referred to as FinTechs).

Toronto-based FundThrough, which operates a business-to-business online lending platform, is one of many emerging Canadian FinTechs. In a Globe and Mail article examining disruption in the financial services sector, Steve Uster, FundThrough’s co-founder and CEO, observes:

“We believe that we are only at the beginning of this trend of startups popping up and filling a hole in financial services by using technology.”

A PwC report examining how Canadian banks are responding to new FinTech market entrants notes that “Canadian banks will employ parallel strategies that comprise collaborating with and leveraging some FinTechs while innovating to compete with others.”

Why partner with the FinTechs? Analysts at National Bank Financial asked the same question in a recent report. “Why, we asked ourselves, is the boring but profitable Canadian oligopoly inviting third parties into their most valuable, profitable business line?” to which they responded, “Simply put, we think they are worried … worried that innovators will nip away at, and ultimately fleece, their Golden Geese.”

How will the banks compete? Victor Dodig, chief executive officer at Canadian Imperial Bank of Commerce, proclaimed in a June 2015 speech that” we are responding with nothing less than a top-to-bottom reinvention of ourselves, and the traditional banking model.”

Summary

The third wave of digital disruption will sweep over healthcare just as it is sweeping over the taxi and financial services industries. Will existing healthcare organizations ride the wave or be sent crashing into the rocks?

In their report entitled The Fight for the Customer: McKinsey Global Banking Annual Review 2015, McKinsey & Company offers a warning I think also applies to the heath sector:

“Those that do not seek to transform may well become somewhat digitized, but will likely be stuck in the middle – outwardly modern, inwardly struggling, and moving slowly toward extinction.”

What are your thoughts on the digital disruption of healthcare? Please share your thoughts with me at michael.martineau@avenant.ca or on my blog at ehealthmusings.ca

On May 18, 2016 from 5:30 pm to 7:30 pm, HIMSS Ontario is hosting a special networking eventing in Ottawa. My good friend and digital health commentator, William (Bill) Pascal, will open the evening with a presentation on the state of digital health maturity in Canada. After the presentation you will have the opportunity to explore craft beer, wine and food pairings. Don’t miss this rare opportunity.

Bill is the former Chief Strategic Advisor, Canadian Medical Association and now Principle, Richard Warren & Associates. He teamed with Roger Girard, former CIO, Manitoba eHealth (and one of my digital health mentors), to prepare the in-depth assessment of digital health maturity in Canada on which his presentation is based. Roger will be delivering the same presentation at similar networking event hosted by HIMSS Ontario in Toronto on the same evening.

HIMSS members: Free.

Non-members: $45 (includes HIMSS ON membership).

Location: Mill St. Brew Pub, 555 Wellington St. Ottawa (site of the former Mill restaurant).

A good friend and former work colleague often remarks that once you have worked as a market analyst, you will always think like a market analyst. This observation rings particularly true around New Year’s when I feel the irresistible urge to offer my prognostications on what’s next for digital health.

This year, rather than offer specific predictions, I offer an overview of three major drivers that I believe will influence digital health priorities and direction in the near future.

Meaningful Use

In what might turn out to be one of the most significant announcements of 2016, Andy Slavitt, Acting Administrator of the U.S. Centers for Medicare and Medicaid Services (CMS), declared:

“The Meaningful Use program as it has existed, will now be effectively over and replaced with something better.”

According to healthIT.gov (a web site operated by the U.S., Office of the National Coordinator for Health Information Technology), Meaningful Use is defined as “using certified electronic health record (EHR) technology to:

Improve quality, safety, efficiency, and reduce health disparities

Engage patients and family

Improve care coordination, and population and public health

Maintain privacy and security of patient health information”

Speaking at the J.P. Morgan Annual Health Care Conference on January 11, 2016, Mr. Slavitt identified what he referred to as the four “themes guiding our implementation” of a Meaningful Use replacement:

Reward healthcare providers for the outcomes they achieve using digital health technologies rather than simply for use of these technologies.

Customized goals that allow solutions to be tailored to practice needs. Slavitt stated that “technology must be user-centered and support physicians, not distract them.”

Levelling the playing field for start-ups and new entrants. This objective will be achieved by requiring open APIs in order to “move away from the lock that early EHR decisions placed on physician organizations” and thereby “allow apps, analytic tools, and connected technologies to get data in and out of an EHR securely.”

Mr. Slavitt proclaimed “we are deadly serious about interoperability” and put technology companies that attempt to “practice ‘data blocking’ in opposition to new regulations” on notice when he stated that such practices “won’t be tolerated.”

Each of these themes reflects issues and challenges that have hampered the effective use of digital health technologies by both healthcare providers and the general public.

While the Meaningful Use program does not apply to Canadian healthcare organizations, it did have and its eventual replacement will have a significant influence on the digital health landscape in Canada.

Digital Health Investment

In their year end review for 2015, Rock Health, a venture fund dedicated to digital health, stated that venture funding for digital health companies in 2015 raised $4.5B. This level of funding was an increase over the record breaking level of digital health investments in 2014 and, according to Rock Health, represents a compound annual growth (CAGR) from 2011-2015 of 32%.

Rock Health noted in their year end review that while “overall venture funding showed a slight dip in 2015, digital health continues to hold a healthy 7% of total venture funding.” They also remarked that investors continue to show their interest in digital health companies and observed that there is a “growing tail of investors who participated in at least one deal.”

This steady level of funding and growing investor interest leads Rock to declare that “digital health is no longer a novelty.”

Rock Health identified three particular digital health categories that exhibited noticeable growth in funding in 2015: personal health tools and tracking, care coordination, and life sciences technologies. They commented that “as the industry faces growing pressure to cut costs, digital health will play a key role in enabling engagement with the end-user and improving communication and coordination.”

Digital Everywhere

Computing technology, once the nearly exclusive realm of geeks and hobbyists, is now an integral part of everyday life for most people.

According to comScore, a global media measurement and analytics company, an average of 29.4 million Canadians per month accessed some form of on-line service during the fourth quarter of 2014. Based on Statistics Canada figures, this on-line community represents just over 80% of the Canadian population.

Not only are a majority of Canadians engaging in some form of online activity, comScore notes that they are increasingly doing so across multiple devices including desktops, laptops, tablets, and smartphones. The number of Canadian mobile subscribers grew 5% from December 2013 to December 2014, with just over 80% of these subscribers owning a smartphone capable of accessing a variety of online services.

The pervasiveness of digital technology is changing how digital health solutions are perceived by end users. Neither patients nor health providers need to be enticed to use digital technology; they do so in most other aspect of their lives. They need only be offered digital health solutions that are both useful and usable.

Summary

By clearly communicating its priorities and future direction, CMS is providing investors with insights that will shape their investment decisions. This investment, if focused more on addressing user needs and less on certifying compliance with meaningful use guidelines, will likely produce digital solutions that end users will embrace and use.

What are your thoughts on digital health trends and drivers? Please share your thoughts with me at michael.martineau@avenant.ca or on my blog at ehealthmusings.ca

She died on a Tuesday. While my mother’s passing this summer was expected given her illness, I was still unprepared for the range of emotions that I have experienced. Tuesday will never be the same.

As the oldest child and the family member most comfortable speaking in front of a crowd, I was asked to prepare and deliver my mother’s eulogy. I found the main theme for this tribute in the words of Maria Shriver, a former First Lady of California and an American journalist:

“Our mothers give us so many gifts. They give us the precious gift of life, of course, but they also leave treasured lessons that can guide us along our journeys even when they are no longer with us.”

My mother left me with many treasured lessons. Her observations on nursing and the use of digital health solutions have shaped my views and influenced my digital health advocacy work.

My mother was a dedicated and caring nurse for whom nursing was as much a calling as it was a career. She always referred to the people to whom she provided care as “her” patients. Whenever we spoke about digital health solutions, she reminded me, often in subtle ways, to consider the needs of the people who use these solutions.

Although my mother was, at best, a computer novice, she saw the value in digitizing healthcare. She bemoaned, however, what she referred to as the “well meaning” attempts to digitize the world in which she worked. She often remarked that it was as if the people developing these systems “never walked the floor.”

Earlier this year I worked with AmericanEHR Partners to analyze data from the annual AmericanEHR Survey on Physician Use of EHR Systems. Among the various topics explored in this survey were respondents’ views regarding the ease of use of their EHR systems.

When asked whether they were satisfied with the ease of use of their EHR system, just over half (53%) of the survey respondents reported that their EHR system was difficult or very difficult to use. Slightly more than one-third (35%) reported that their EHR system was easy or very easy to use.

One of the more striking variations in the survey data became apparent when respondents were grouped based on whether they were satisfied with their EHR system.

A significant majority (89%) of those who indicated that they were satisfied or very satisfied with their EHR system also reported that they found their EHR system was easy or very easy to use.

Conversely, for those respondents who indicated that they were dissatisfied with their EHR system, a significant majority (90%) also reported that they found their EHR system was difficult or very difficult to use.

In a New York Times commentary, Robert M. Watcher, author of “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age”, writes:

Why do digital solutions like the iPhone or Google’s Gmail have higher user satisfaction ratings than most digital health solutions? Many experts suggest that an intense focus on usability and user experience is one reason for this difference.

Bennett Lauber, Chief Experience officer for The Usability People, LLC, and an active member of the U.S. Office of the National Coordinator for Health IT (ONC) Policy Committee’s Implementation, Usability, and Safety Workgroup, observes:

“Usability in healthcare can be difficult to achieve … A useable healthcare system must be designed to match the mental models and workflow of its users. A usable EHR needs to work (effective), work well (efficient), and not cause any unnecessary frustration (satisfying).”

The ONC appears to agree with the need for a greater focus on usability and the use of tools that contribute to it. Their 2014 certification criteria for electronic health record solutions includes a requirement that vendors attest to using user centered design processes as well as report on the results of their usability testing.

Unfortunately, according to a report from the National Center for Human Factors in Healthcare, many of the 50 electronic health record (EHR) solution vendors serving the highest number of healthcare providers did not meet the ONC’s usability requirements.

Using data submitted by the vendors to the ONC as part of the certification process, researchers at the National Center for Human Factors in Healthcare found that 34% of these vendors had not met the ONC certification requirement of stating their user-centered design process.

Perhaps more concerning, 63% of these same vendors used less than the standard of 15 participants during the usability tests of their EHRs while only only 22% used at least 15 participants with clinical backgrounds. Nearly one in five (17%) vendors used no physician participants and 5% used their own employees when conducting usability testing.

Researchers commented in the report that “the lack of adherence to usability testing may be a major factor contributing to the poor usability experienced by clinicians.”

So, what happens when digital health solutions are as usable and as useful as other digital solutions? When asked by Robert Watcher what the equivalent of the “Jeopardy!” victory would be in healthcare, Eric Brown, lead engineer of the Watson Health team at IBM replied: “It’ll be when we have a technology that physicians suddenly can’t live without.”

How do you rate the usability of the digital health solutions that you use? Are there solutions that you or your user community can’t live without? Please share your thoughts by commenting on this blog post.